012-3-11 Definition Urinary Tract a Urinary tract infections are acute Infections(UTIs) chronic inflammatory reactions caused by proliferation of pathogenic microorganisms Tongying Zhu existing in the urinary tract Huashan Hospital Fudan Definition(cont Classification of utis a Infections of the urinary tract can be subdivided into two general anatomic Asymptomatic bacteriuria Symptoms O Lower tract infection(urethritis and cystitis radic(sI UT1/6 mo and s2 UTIs/yr) a Upper tract infection(pyelonephritis, intrarenal Recurrent(22 UTIs/ 6 mo or 23 UTls/yr) and perinephric abscesses) Reinfection Complicating factors Complicated(see text UTl=urinary tract infection. Epidemiology Epidemiology(cont s Worldwide, at least 150 million cases of symptomatic UTIs who have utis is lower nales, who are also more likely to hav number of cases ymptomatic bacteriuria. a 90% of patients have cystitis and 10% have pyelonephritis (short urethra, also be the result of sexual abuse n Sporadic in about 70% of patients and recurrent in 25%. m In young man under 50, UTIs are rare and are often the result n About 2% have complicated infections related to factors that of underlying infections of the prostate. tic and asymptomatic UTIs erity are included, the Women often the result of atrophic vagin equency of complicated infections is about 8%. ence of prostate hyperplasia or cancer
2012-3-11 1 Urinary Tract Infections(UTIs) Tongying Zhu Huashan Hospital Fudan University Definition Urinary tract infections are acute or chronic inflammatory reactions caused by proliferation of pathogenic microorganisms existing in the urinary tract. Definition(cont.) Infections of the urinary tract can be subdivided into two general anatomic categories: Lower tract infection (urethritis and cystitis) Upper tract infection (pyelonephritis, intrarenal and perinephric abscesses) Classification : Table 292-1 Classification of UTIs Epidemiology Worldwide, at least 150 million cases of symptomatic UTIs occur each year. The number of patients who have UTIs is lower than the number of cases. 90% of patients have cystitis and 10% have pyelonephritis 90% of patients have cystitis and 10% have pyelonephritis. Sporadic in about 70% of patients and recurrent in 25%. About 2% have complicated infections related to factors that increase the risk of establishment and management of bacteriuria. If factors that can increase the severity are included, the frequency of complicated infections is about 8%. Epidemiology (cont.) In very young child, UTIs more common in boy. Later in childhood and adult, symptomatic UTIs are more common in females, who are also more likely to have asymptomatic bacteriuria. (short urethra also be the result of sexual abuse) (short urethra, also be the result of sexual abuse) In young man under 50, UTIs are rare and are often the result of underlying infections of the prostate. In elderly people, both symptomatic and asymptomatic UTIs are common. Women: often the result of atrophic vaginal mucosa Men: often the consequence of prostate hyperplasia or cancer
012-3-11 Microbial Etiology of UTIs Epidemiology(cont NICAL CHARACTERISTICs a UTls is also the most common type of hospital-acquired infection because of the frequent use of bladder-catheters (catheter-associated infection) Most comcon daring sanmar Urethral syndrome Pathogenesis s In the vast majority of UTIs, bacteria gain access to the n About 1/3 n with dysuria and frequency have either an adder via the urethra m Ascent of bacteria from the bladder may follow and is mpletely sterile cultures -previously defined as having probably the pathway for most pyelonephritis urethral syndrome. a y no pyuria(and little objective evidence of infection) s In rare cases, bacteriuria and funguria may result from D Low counts(102 to 10ml)of typical bactenal uropathogens n These bacteria are probably the causative agents and associated with genous pyelonephritis occurs most often in ed patients who are either chronically ill or D Can be isolated from a suprapubic aspirate receiving immuno-suppresive therapy rimary focus of the infection is usually an infection at a site outside the renal tract, such as endocarditis Pathogenesis(cont Pathogenesis(cont s The vaginal introitus and distal urethra are normally colonized by diphtheroids, streptococcal and a In the normal male urethra. the distance between the staphylococcal species, lactobacilli, but not by the enteric G(-)bacilli end of the urethra and the bladder is too long to allow ding transport of bacteria to the bladder The factors that predispose to periurethral colonization with G()bacilli remain poorly understood. de when there is a turbulent urine flow a Alteration of the normal vaginal flora by antibiotics, other with a stricture or obstruction of the urethra. as a prostate hyperplasia, and when the patient has a appear to play an important role. n Loss of the normally dominant H2O2-producing ctobacilli in the vaginal flora appears to facilitate colonization by Ecoli
2012-3-11 2 Epidemiology (cont.) UTIs is also the most common type of hospital-acquired infection because of the frequent use of bladder-catheters. (catheter- associated infection) Microbial Etiology of UTIs Urethral syndrome About 1/3 of women with dysuria and frequency have either an insignificant number of bacteria in midstream urine cultures or completely sterile cultures ---previously defined as having urethral syndrome. ¼ no pyuria (and little objective evidence of infection) ¾ pyuria Low counts(102 to 104/ml) of typical bacterial uropathogens These bacteria are probably the causative agents and associated with pyuria Can be isolated from a suprapubic aspirate Respond to appropriate antimicrobial therapy Pathogenesis In the vast majority of UTIs, bacteria gain access to the bladder via the urethra. Ascent of bacteria from the bladder may follow and is probably the pathway for most pyelonephritis. In rare cases, bacteriuria and funguria may result from In rare cases, bacteriuria and funguria may result from the hematogenous dissemination of bacteria to the kidneys. Hematogenous pyelonephritis occurs most often in debilitated patients who are either chronically ill or receiving immuno-suppresive therapy. Primary focus of the infection is usually an infection at a site outside the renal tract, such as endocarditis. Pathogenesis(cont.) The vaginal introitus and distal urethra are normally colonized by diphtheroids, streptococcal and staphylococcal species, lactobacilli, but not by the enteric G(-) bacilli. The factors that predispose to periurethral colonization with G(-) bacilli remain poorly understood. Alteration of the normal vaginal flora by antibiotics, other genital infections, or contraceptives (esp. spermicide) appear to play an important role. Loss of the normally dominant H2O2-producing lactobacilli in the vaginal flora appears to facilitate colonization by E.coli. Pathogenesis(cont.) In the normal male urethra, the distance between the end of the urethra and the bladder is too long to allow ascending transport of bacteria to the bladder. Transport is possible when there is a turbulent urine flow (such as with a stricture or obstruction of the urethra, as a result of prostate hyperplasia, and when the patient has a bladder catheter )
012-3-11 Pathogenesis(cont) Pathogenesis(cont) u When bacteria have reached the bl a The female urethra is short and allows transport of ia is facilitated by incom bacteria to the bladder in healthy individuals With many uropathogens, such tra is facilitated by bladder through the ureter to the renal pelvis and the renal adherence of the bacteria to urethral epithelial cells parenchyma. n Sexual intercourse results in increased numbers of a This transport may be facilitated b cteria in the periurethral area of the vagina and the mic defects of the ureters or the kidneys distal part of the urethra, increasing the risk of vesicoureteral reflux o adhesion to the ureter mucosa Pathogenesis(cont Bacterial virulence factors a Uropathogenic E Coli: a Whether bladder infection occurs depends a belongs to a small no of specific o, K and H serogroups on interacting effects of the pathogenicity n Easy to adherence to uroepithelial cells(fimbriae) D After attachment, initiates some important events in epithelial of the strain the inoculum size. and the local and systemic host defense mechanism a These properties are not needed for infection of the Bladder catheterization and utis Host factors complicating bacteriuria FACTORS s Bladder catheterization leads to bacteriuria or funguria in almost all patients who have had their catheters for more the growth of microorganisn a Urosepsis, resulting from diss acteria from the urine to the blood may ha or changing the catheter. infections involving the kidneys a The urethral mucosa may also be damaged by crystals Chronic pyelonephritis that form on the catheter surface
2012-3-11 3 Pathogenesis(cont.) The female urethra is short and allows transport of bacteria to the bladder in healthy individuals. With many uropathogens such tr With many uropathogens, such transport ansport is facilitated by is facilitated by adherence of the bacteria to urethral epithelial cells. Sexual intercourse results in increased numbers of bacteria in the periurethral area of the vagina and the distal part of the urethra, increasing the risk of bacteriuria. Pathogenesis(cont.) When bacteria have reached the bladder, the establishment of bacteriuria is facilitated by incomplete bladder emptying Pyelonephritis results from ascending bacteriuria from the bladder through the ureter to the renal pelvis and the renal bladder through the ureter to the renal pelvis and the renal parenchyma. This transport may be facilitated by: host factors such as anatomic defects of the ureters or the kidneys, vesicoureteral reflux adhesion to the ureter mucosa Pathogenesis(cont.) Whether bladder infection occurs depends on interacting effects of the pathogenicity of the strain, the inoculum size, and the local and systemic host defense mechanism. Bacterial Virulence Factors Uropathogenic E. Coli: belongs to a small no. of specific O, K and H serogroups. Easy to adherence to uroepithelial cells (fimbriae) After attachment initiates some i After attachment, initiates some important mportant events in epithelial events in epithelial cells(secretion IL6, IL8, induction of apoptosis and epithelial cell desquamation) Secretion hemolysin and aerobactin and are resistant to the bactericidal action of human serum These properties are not needed for infection of the compromised urinary tract Host factors complicating bacteriuria Bladder catheterization and UTIs Bladder catheterization leads to bacteriuria or funguria in almost all patients who have had their catheters for more than 1 week. Formation of a biofilm on the catheter surfaces facilitates the gro th of microorganisms the growth of microorganisms. Urosepsis, resulting from disssemination of bacteria from the urine to the blood may happen during the removing or changing the catheter. The urethral mucosa may also be damaged by crystals that form on the catheter surface
012-3-11 Pregnancy and UTIs Pregnancy and UTls(cont a UTIs are detected in 2-8%of pregnant women. ition to upper tract infection during s Asymptomatic bacteriuria frequently harbor organisms that ess virulent than those causing symptomatic infections. n Temporary incompetence of the vesicoureteral valv m Fully 20-30% of pregnant women with asymptomatic a Bladder catheterization during or after delivery bacteriuria subsequntly develop pyelonephritis. a Risk of UTIs during pregnancy a Increased incidences of low-birth-weight infants 口 Premature delivery Genetic Factors and UTIs P blood group a Host genetic factors influence susceptibility to UTIs m P blood group system, classification of human blood based on the presence of any of three substances experienced recurrent Utis than among controls. known as the P. P, and Pk ans on the surfaces of s The number and type of receptors which bacteria may attach are at opart geneticaly a There are five phenotypes in the P blood group system: P, P2, P, P2, P a P2 phenotype -consists of the P and P< antigens a Many of these structures are components of blood group antigens and are present on both erythrocytes and o P, phenotype---Pk antigen o Extremely uroepithelial cel a p phenotype-no antigens unc ommon P blood group antigens assigned roles in the P blood group antigens assigned roles in the pathophysiology of UTIs pathophysiology of UTIs(cont) a The P blood group antigens are glycan structures, expressed not only on red cells, but also on other tissues, including the enotype has a higher risk, relative to P2 phenotype is of utis by the observation that various uropathogenic observation that adhesion of strains of Escherichia coli express adhesins that bind to the elonephritic strain of E. coli to renal tissue is mediated Gala1-4Gal moiety of the Pk and P, antigens acterial adhesin specific for the Gala 1-4Gal structure and that deficiency of the adhesin severely s The P, detern attenuates the pyelonephritic phenotype of the organism. attachment of bacteria to the lining of the urinary tracing individuals and may facilitate bacterial infection by media
2012-3-11 4 Pregnancy and UTIs UTIs are detected in 2-8% of pregnant women. Asymptomatic bacteriuria frequently harbor organisms that less virulent than those causing symptomatic infections. Fully 20-30% of pregnant women with asymptomatic bacteriuria subsequntly develop pyelonephritis. Pregnancy and UTIs(cont.) The predisposition to upper tract infection during pregnancy results from: Decreased ureteral tone Decreased ureteral peristalsis Decreased ureteral peristalsis Temporary incompetence of the vesicoureteral valve Bladder catheterization during or after delivery Risk of UTIs during pregnancy Increased incidences of low-birth-weight infants Premature delivery Newborn mortality Genetic Factors and UTIs Host genetic factors influence susceptibility to UTIs. A maternal history of UTI is more often found among women who have experienced recurrent UTIs than among controls. The number and type of receptors on uroepithelial cells to which bacteria may attach are at least in part genetically determined. Many of these structures are components of blood group antigens and are present on both erythrocytes and uroepithelial cells P blood group P blood group system, classification of human blood based on the presence of any of three substances known as the P, P1, and Pk antigens on the surfaces of red blood cells. There are five phenotypes in the P blood group system: P1, P2, P1 k, P2 k, P P1 phenotype --- displays all three P antigens P2 phenotype --- consists of the P and Pk antigens P1 k phenotype -- P1 and Pk antigens P2 k phenotype --- Pk antigen only p phenotype --- no antigens Extremely uncommon P blood group antigens assigned roles in the pathophysiology of UTIs The P blood group antigens are glycan structures , expressed not only on red cells, but also on other tissues, including the urothelium . A role for P blood group antigens in the pathogenesis of UTIs is implied by the observation that various uropathogenic strains of Escherichia coli express adhesins that bind to the Galα1–4Gal moiety of the Pk and P1 antigens. The P1 determinant is expressed on the urothelium of P1 individuals and may facilitate bacterial infection by mediating attachment of bacteria to the lining of the urinary tract P blood group antigens assigned roles in the pathophysiology of UTIs (cont.) This hypothesis is supported by the observation that P1 phenotype has a higher risk, relative to P2 phenotype, for UTIs and pyelonephritis. It is also supported by the observation that adhesion of a pyelonephritic strain of E. coli to renal tissue is mediated by a bacterial adhesin specific for the Galα1–4Gal structure and that deficiency of the adhesin severely attenuates the pyelonephritic phenotype of the organism
012-3-11 Clinical manifestations Cystitis s The onset of cystitis is rapid, and symptoms develop a Cystitis over less than 24 hours s Patients with cystitis usually report dysuria, frequency, a Pyelonephritis urgency, and suprapubic pain a Urine is bloody in -30% of cases. a Urosepsis s Clinically, it is often impossible to differentiate between cystitis and urethritis caused by chlamydia, ureaplasma Cystitis(cont. Py a Fever is unusual among patients with cystitis a rapid onset, with or without a The patients are often with the fever and flank pain Cystitis patients normally have symptoms for 3 to 5 days m About 1/3 of patients develop bacteremia Antibiotic therapy does not markedly reduce the duration a The typical flank pain results from inflammation and edema of the renal parenchyma. Differential diagnosis of pyelonephritis Urosepsis is renal calculi. which may result in a similar location of the pain but ning condition caused by characteristically do not cause fever. ition of bacteria from the urine in a patient with with flank pain similar to that in a patient with right-sided pyelonephritis (and most. eason for urosepsis is withdrawal nsertion)of a bladder catheter (urinanalysis can make differential diagnosis) a Therefore, uroseptic patients do not always have a renal infection
2012-3-11 5 Clinical manifestations Cystitis Pyelonephritis Urosepsis Cystitis The onset of cystitis is rapid, and symptoms develop over less than 24 hours. Patients with cystitis usually report dysuria, frequency, urgency and suprapubic pain urgency, and suprapubic pain. Urine is bloody in ～30% of cases. Clinically, it is often impossible to differentiate between cystitis and urethritis caused by chlamydia, ureaplasma, or gonococci. Cystitis (cont.) Fever is unusual among patients with cystitis. In sexually active women, cystitis commonly occurs 24 to 48 hours after intercourse esp without post 48 hours after intercourse, esp. without post-voiding voiding . Cystitis patients normally have symptoms for 3 to 5 days. Antibiotic therapy does not markedly reduce the duration. Pyelonephritis Pyelonephritis also has a rapid onset, with or without preceding cystitis symptoms. The patients are often with the The patients are often with the fever and flank pain flank pain. About 1/3 of patients develop bacteremia. The typical flank pain results from inflammation and edema of the renal parenchyma. Differential diagnosis of pyelonephritis An important differential diagnosis is renal calculi, which may result in a similar location of the pain but characteristically do not cause fever. Patients with appendicitis and cholecystitis can present with flank pain similar to that in a patient with right-sided pyelonephritis. (urinanalysis can make differential diagnosis) Urosepsis Urosepsis is a life-threatening condition caused by dissemination of bacteria from the urine in a patient with bacteriuria. The most common reason for urosepsis is withdrawal (and sometimes insertion) of a bladder catheter. Therefore, uroseptic patients do not always have a renal infection
012-3-11 Clinical symptoms of Utls Diagnosis TYPE OF URINARY TRACT INFECTION TYPICAL SYMPTOMS quent voiding a Laboratory findings uming during and after voiding ■ maging Pyelonephritis Flank pains a Differetial diagnosis Cystitis symptoms(may be absent) Septic shock Urinanalysis Urine culture a Pyuria should be demonstrated in patients with acute a The ways to get the urine sample UTIs, and its absence calls the diagnosis into question a The most reliable result is obtained if the sample is ■ Tested in3ways (frequently used in infants but rarely in older children urine and counting n The second best technique is to use a leukocytes esterase stick a Sampling by bladder catheterization st, which is highly sensitive and allows a crude quantification of a 2% risk of introducing bacteria into and subsequently causing bacteriuria) midstream urine sample and is not recommended (requires the patient to be well informed about the Correct sampling procedure A nitrite test can be used for screening of bacteriuria n Men should withdraw the foreskin and women should keep the labia apart m It's a stick test that demonstrates the presence of nitrite s Washing of the genital tract before sampling is no metabolize nitrate to nitrite which can be demonstrated by a color reaction on a paper stick. m During voiding, the first and last parts of the urine should s G(+)bacteria and fungi do not metab m The technique is rapid (<1 min) and m It has a high degree of specificity but is rather insensitive After sampling, the urine should be chilled(but not frozen)
2012-3-11 6 Clinical symptoms of UTIs Diagnosis Laboratory findings Imaging Differetial diagnosis Urinanalysis Pyuria should be demonstrated in patients with acute UTIs, and its absence calls the diagnosis into question. Tested in 3 ways: Best done by staining uncentri Best done by staining uncentrifuged urine and counting urine and counting leukocytes in a Bϋrker chamber. The second best technique is to use a leukocytes esterase stick test, which is highly sensitive and allows a crude quantification of pyuria. The technique of counting leukocytes in the sediment obtained after centrifugation was once used routinely, but it is impresice and is not recommended. Urine culture The ways to get the urine sample: The most reliable result is obtained if the sample is taken by suprapubic aspiration (frequentlu used in infants but rarely in older children and adults and adults) Sampling by bladder catheterization (carries about a 2% risk of introducing bacteria into the bladder and subsequently causing bacteriuria) To collect a midstream urine sample (requires the patient to be well informed about the sampling procedure) Correct sampling procedure Men should withdraw the foreskin, and women should keep the labia apart. Washing of the genital tract before sampling is not recommended. During voiding, the first and last parts of the urine should not be sampled. After sampling, the urine should be chilled (but not frozen) to prevent growth during transportation to the lab. A nitrite test can be used for screening of bacteriuria It’s a stick test that demonstrates the presence of nitrite in the urine. G(-) bacteria, with the exception of P. aeruginosa, metabolize nitrate to nitrite, which can be demonstrated by a color reaction on a paper stick. G(+) bacteria and fungi do not metabolize nitrate. The technique is rapid (<1 min) and inexpensive. It has a high degree of specificity but is rather insensitive It is not suitable for use in patients with recurrent infections (enterococal is common)
012-3-11 The result of the culture Pyuria in the absence of bacteriuria m Bacteria are usually present in the urine in large number (105m) a Sterile pyuria may indicate n Samples of urine from the ureters or renal pelvis may a Infection with unusual bacterial agents, such as mycobacterium tuberculosis ( the urine sample should be obtained for direct m The presence of bacteriuria of any degree in suprapubic berculosis catheterization usually indicates infection. May be demonstrated in noninfectious urologic nditions, such as interstitial nephritis, polysystic lgh osmolarity, low PH), urine inhibits bacterial multiplication, sulting in relatively low bacterial colony counts despite Image Blood culture in diagnosis a Radiography and ultrasound examination are not helpful in the acute pyelonephritis unless there is suspicion of a a Blood cultures should be obtained in all blockage of the urine flow patients with suspected pyelonephritis or m When th t has recovered, such investigatio those with recurrent ating factors a It is recommended that at least two cultures be obtained s pyelography or ultrasound examination is enough For the diagnosis of vesicoureteral reflux, special radiographic techniques are used I Differential diagnosis (acute pyelonephritis and cystitis) Differential diagnosis(cont) (acute pyelonephritis and cystitis s Patients with acute pyelonephritis, have increased levels a When a patient has become afebrile, the diagnosis of cute pyelonephritis can be supported by testing urine a The erythrocyte sedimentation rate is less helpful, osmolality, which is markedly reduced for at least 1 because it takes several days to increase in acute month after the onset of symptoms ften be demonstrated in urine sediment a Demonstration of antibody-coated bacteria in the urine is neither sensitive nor specific and is no longer ecommended
2012-3-11 7 The result of the culture Bacteria are usually present in the urine in large number (105/ml). Samples of urine from the ureters or renal pelvis may contain< 105/ml bacteria and yet indicate infection. The presence of bacteriuria of any degree in suprapubic aspirates or of 102/ml bacteria of urine obtained by catheterization usually indicates infection. In some circumstances (antibiotic treatment, high urea conc. High osmolarity, low PH), urine inhibits bacterial multiplication, resulting in relatively low bacterial colony counts despite infection. Pyuria in the absence of bacteriuria Sterile pyuria may indicate: Infection with unusual bacterial agents, such as mycobacterium tuberculosis. (the urine sample should be obtained for direct microscopy and culture for mycobacterium microscopy and culture for mycobacterium tuberculosis) May be demonstrated in noninfectious urologic conditions, such as interstitial nephritis, polysystic disease, SLE, nephrocalcinosis. Blood culture in diagnosis Blood cultures should be obtained in all patients with suspected pyelonephritis or urosepsis. It is recommended that at least two cultures be obtained. Image Radiography and ultrasound examination are not helpful in the acute pyelonephritis unless there is suspicion of a blockage of the urine flow. When the patient has recovered, such investigations are recommended in those with recurrent infections to exclude complicating factors. pyelography or ultrasound examination is enough. For the diagnosis of vesicoureteral reflux, special radiographic techniques are used. Differential diagnosis (acute pyelonephritis and cystitis) Patients with acute pyelonephritis, have increased levels of C-reactive protein in blood. The erythrocyte sedimentation rate erythrocyte sedimentation rate is less helpful, is less helpful, because it takes several days to increase in acute pyelonephritis. In patients with acute pyelonephritis, leukocyte casts can often be demonstrated in urine sediment. Differential diagnosis (cont.) (acute pyelonephritis and cystitis) When a patient has become afebrile, the diagnosis of acute pyelonephritis can be supported by testing urine osmolality, y which is markedly reduced for at least 1 month after the onset of symptoms. Demonstration of antibody-coated bacteria in the urine is neither sensitive nor specific and is no longer recommended
012-3-11 Treatment of utis The principles of UTIs treatment m All symptomatic UTIs should be treated and inflammatory secretions from the urine s The purpose of early treatment of cystitis is to reduce the risk of progression to pyelonephritis nosis. but also to the treatment(direct m In patients with pyelonephritis, early treatment is reduce the duration of symptoms n eliminate microorganisms from the renal parenchyma therapy reduce the risk of dissemination to the blood (3-5days), while upper tract infection required longer The principles of UTIs treatment(cont Antibiotics used to treat cystitis a If common antibiotics are ineffective. the 80/400 mg qTh for 3 days following microorganisms should be considered mg qsh for 5-7 days mycoplasm Antibiotics used to treat pyelonephrits Antibiotics used to treat pyelonephrits OUTE OF AND ANTIMICROBIAL AL Amoxicillin/clavulanic acid 500 mg(amoxicillin Only step-down therapy I Eyal Cefuroxime axetil Only step-down therapy Cefpodoxime proxetil Only step-down therapy Cefixime Only step-down therap s me Ceftibuten Only step-down therap Clprotloacin 100 mg q12h Levofloxacin 250 mg/day
2012-3-11 8 Treatment of UTIs All symptomatic UTIs should be treated. The purpose of early treatment of cystitis is to reduce the risk of progression to pyelonephritis. In patients with pyelonephritis, early treatment is important to: reduce the duration of symptoms, eliminate microorganisms from the renal parenchyma, reduce the risk of dissemination to the blood The principles of UTIs treatment Drink more water to promote the elimination of bacteria and inflammatory secretions from the urine. Factors predisposing to infection should be identified and corrected Urine culture is important not only to the diagnosis, but also to the treatment (direct therapy ) as well. Relilef of clinical symptoms does not always indicate bacteriologic cure In general, uncomplicated infections confined to the lower urinary tract respond to short courses of therapy (3-5days), while upper tract infection required longer treatment (14 dalys). The principles of UTIs treatment(cont.) If common antibiotics are ineffective, the following microorganisms should be considered: Resistant bacteria Resistant bacteria Unusual microorganisms, including anaerobic bacteria, mycobacterium tuberculosis, L bacterium, mycoplasma Antibiotics used to treat cystitis Antibiotics used to treat pyelonephrits Antibiotics used to treat pyelonephrits
012-3-11 Treatment of bacteriuria Treatment of urosepsis treated unless the patient is febrile or has other evidence treatment must start as early as possible of systemic infection a Antibiotis should be given intravenously m Administration of antibiotics to catheterized patients a Previous antibiotic treatment should always be ascertained, because such treatment may have with asymptomatic bacteriuria inevitably results in multi- resulted in resistant organisms resistant and difficult-to-treat organisms Treatment of funguria Follow-up a Funguria can be treated with fluconazole 400 a Patients with sporadic, uncomplicated cystitis do not equire follow-up mg once daily for 1 day, followed by 200 mg once daily for 7 to 14 days a Patients with symptomatic recurrences, pyelonephritis, or complicated UTI should be observed a Funguria in catheterized patients should be m Follow-up cultures are important because bacteriuria treated only when there is a symptomatic UTI may persist and cause renal damage in afebri Follow-up procedures in patients with Decision process for upper(pyelonephritis) UTIs other than sporadic cystitis and lower(cystitis) urinary tract infections PYELONEPHRITIS PROCEDURE RECOMMENDATION SIGNS AND SYMPTOMS Urine culture All patients with pyelonephritis, complicated fections, or frequent recurrences: 4-5 days and Puna test Always pertorm together with unne culture 4-5 days and 3 wk after treatment Flank pain After py to exclude scars from childhood IAGNOSIS Puna Nitrite test Normally positive Normally positi Serum creatinine deddy: 3-4 wk after treatment in tients with pyelonephritis -eactive protein creased Urine osmolality Verification of suspected pyelonephritis Blood cultures Negative Positive in*3006
2012-3-11 9 Treatment of bacteriuria Bacteriuria in patients with catheters should not be treated unless the patient is febrile or has other evidence of systemic infection. Administration of antibiotics to catheterizaed patients with asymptomatic bacteriuria inevitably results in multiresistant and difficult-to-treat organisms Treatment of urosepsis In patients with suspected urosepsis, antibiotic treatment must start as early as possible. Antibiotis should be g y iven intravenously. Previous antibiotic treatment should always be ascertained, because such treatment may have resulted in resistant organisms. Treatment of funguria Funguria can be treated with fluconazole 400 mg once daily for 1 day, followed by 200 mg once daily y for 7 to 14 days. Funguria in catheterized patients should be treated only when there is a symptomatic UTI. Follow-up Patients with sporadic, uncomplicated cystitis do not require follow-up. Patients with symptomatic recurrences, pyelonephritis, or complicated UTI should be observed. Follow-up cultures are important because bacteriuria may persist and cause renal damage in afebrile pyelonephritis patients. Follow-up procedures in patients with UTIs other than sporadic cystitis Decision process for upper(pyelonephritis) and lower(cystitis) urinary tract infections
012-3-11 Decision process for upper(pyelonephritis Prevention and lower(cystitis) urinary tract infections CYSTITIS PYELONEPHRITIS s The most important is for sexually active women to urinate shortly after sexual intercourse TREATMENT n Another useful suggestion is for patients with recurrent trimethoprim. UTIs to practice double or triple voiding Second line Fluoroquinolone Injectable cephalosporin s Increased fluid intake was previously advocate 5-7 days tal of w ulfonamides: there are no obvious benefits of excessive Pregnant women injectable cephalosporin for 5-7 days for 2 wk Prevention(cont Antimicrobial prophylaxis a Cranberry products have been pr a Prophylaxis is sometimes used in patients wit evention of recurrent UTIs. An of frequently recurring UTIs, esp. when there are no est that these products might have a low defined, treatable complications ventive effect in young and middle-aged women, but the use of cranberries is not recommended s In such patients, one daily dose of nitrofurantoin 100mg, taken at bedtime, is recommended mucosa and recurrent symptomatic UTIs, replacement herapy with oral or vaginal estriol should be catheterized patients because it results in the selection of micrbes resistant to the antimicrobial used considered ognosIs Prognosis(cont a The prognosis of uncomplicated cystitis and pyelonephritis is generally good unless urosepsis occurs om childhood pyelonephritis, chronic pyelonephritis er lead to a further ction of renal functio a Patients with urosepsis have a poor prognosis, with ■ calculi or the worsening of existing ones diseases, as well as inadequate antibiotic treatment. 10
2012-3-11 10 Decision process for upper(pyelonephritis) and lower(cystitis) urinary tract infections Prevention The most important is for sexually active women to urinate shortly after sexual intercourse. Another usefule suggestion is for patients with recurrent UTIs to practice double or triple voiding UTIs to practice double or triple voiding. Increased fluid intake was previously advocated, probably because of the risk of crystalluria with oldsulfonamides; there are no obvious benefits of excessive diuresis. Prevention (cont.) Cranberry products have been proposed for the prevention of recurrent UTIs. Analyses of studies suggest that these products might have a low preventive effect in young and middle-aged women, but the use of cranberries is not recommended. but the use of cranberries is not recommended. In postmenopausal women with atrophic vaginal mucosa and recurrent symptomatic UTIs, replacement therapy with oral or vaginal estriol should be considered. Antimicrobial prophylaxis Prophylaxis is sometimes used in patients with frequently recurring UTIs, esp. when there are no defined, treatable complications. In such patients, one daily dose of nitrofurantoin 50- 100mg, taken at bedtime, is recommended. Antimicrobial prophylaxis should not be used in catheterized patients because it results in the selection of micrbes resistant to the antimicrobial used. Prognosis The prognosis of uncomplicated cystitis and pyelonephritis is generally good unless urosepsis occurs. Secondary morbidity is rare. Patients with urosepsis have a poor prognosis, with fatality rates of about 30% or higher. Factors increasing the risk of death are advanced age and underlying diseases, as well as inadequate antibiotic treatment. Prognosis(cont.) In patients with complications such as renal scars from childhood pyelonephritis, chronic pyelonephritis or glomerulonephritis, or other chronic renal diseases, acute pyelonephritis may lead to a further reduction of renal function. Infections with Proteus species or other ammoniaproducing organisms may lead to the formation of calculi or the worsening of existing ones